Pharmacy-- Conjunctivitis

PATIENT DETAILS

Name: [Patient Name] Phone number: [Patient Phone Number] Personal Health Number (PHN): [Patient PHN]

GENERAL

PharmaNet has been checked. [Document eligibility.]

REASON FOR VISIT

[Chief complaint]

ASSESSMENT

[Patient name] reports [document reported symptoms (e.g. red irritated eye, discharge, etc.) - Location (right/left eye or bilateral) - Onset/duration - Alleviating/exacerbating factors - Associated symptoms (e.g. fever) - Previous episodes and treatment history - Recent viral infection - Social history (e.g. exposure, contact lens use, pets)] [Document observations made or examination findings. E.g. discharge (watery or mucopurulent), conjunctival redness, eyelid swelling.]

RED FLAGS/REFERRAL INDICATIONS

[Only include this section if there are any red flag symptoms, unclear diagnosis, or indications for referral. This can include eye pain, associated headache, nausea/vomiting, immunocompromised patient, prior history of HSV, visual impairment/disturbance, photophobia, periorbital erythema, periorbital rash, contact lens wearer.]

PAST MEDICAL HISTORY

[Document past medical history.]

CURRENT MEDICATIONS

[Document all current medications, including OTC and natural health treatments. Document if confirmed by checking PharmaNet.]

ALLERGIES

[Document allergies to drugs, foods, animals, and environmental agents.]

DIAGNOSIS

Conjunctivitis

RECOMMENDATIONS

- [Patient education: Document any patient education given] - Self care advice: [Patient name] is advised to wash [pronoun] hands frequently, avoid rubbing [pronoun] eyes, disinfect surfaces in the household, wash [pronoun] pillowcases daily and avoid sharing towels. Any contaminated eye drop bottles or cosmetics should be discarded. - [Treatment: Document details of any over the counter (OTC) or prescription eye drops that are recommended, including strength, frequency, and instructions.] - [Patient name] has been informed that they can fill their prescription at any pharmacy of their choosing.

MONITORING/FOLLOW UP

- Follow up in 2-3 days to assess response to treatment. - [Provider notified: document if patient’s provider has been notified and if yes note their name and practice information.]

Date

[Date of Note]

PHARMACY INFORMATION

Pharmacy name: [Clinic Name] Pharmacy phone number: [Pharmacy Phone Number] Pharmacy address: [Pharmacy Address] Pharmacist name: [Pharmacist Name] Pharmacist license number: [Pharmacist License Number]